Pharmacologic Therapy

Regardless of the cause, the mainstay of treatment for dry eye is artificial tears. Artificial tears augment the tear film topically and provide relief. If a patient uses artificial tears more than four times daily, recommend a preservative-free formulation. Preservative-free formulations are also appropriate if the patient develops an allergy to ophthalmic preservatives. Artificial tears are available in gel, ointment, and emulsion forms that provide a longer duration of relief and may allow for less frequent instilla-

tion. Ointment use is appropriate at bedtime.

Anti-inflammatory agents may be used in conjunction with artificial tears. The only approved agent is cyclosporine emulsion. Administered topically, the exact mechanism is unknown but it is thought to act as a partial immunomodulator suppressing ocular inflammation. Cyclosporine emulsion increases tear production in some patients. Fifteen minutes should elapse after instillation of cyclosporine before artificial tears are instilled.34 Use of topical corticosteroids for short periods (e.g., 2

weeks) may suppress inflammation and ocular irritation symptoms. No topical cor-

ticosteroid is approved for this indication, however.

The oral cholinergic agonists pilocarpine and cevimeline are used for patients with combined dry eye and dry mouth (e.g., Sjogren's syndrome) or severe dry eye. By binding to muscarinic receptors, the cholinergic agonists may increase tear production. Excessive sweating is a common side effect with pilocarpine and may limit its use (Table 63-12).

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